IFMCP

how to test for food allergies?

1. "Gold standard" = Elimination Diet w/ double blind oral food challenge 2. skin prick test 3. IgE serum testing"useful but not diagnostic"

Therapeutic Options for Food Allergies

1. avoidance including cross reactivity 2. allergy shots 3. SLIT-SubLingualImmunoTherapy 4. Address Intestinal Permeability 5. Address Microbiome

90% of all acute food allergies are:

1.Dairy 2.Eggs 3.Peanuts 4.Wheat 5.Soy 6.Fish 7.Shellfish 8.Tree nuts -walnuts, cashews, & almonds

how many essential vitamins?

13

omega 3 fatty acids therapeutic dosages

30-75 lbs = at least 1 g/d (Total Omega 3's) 76-125 lbs = at least 2g/d (Total Omega 3's) > 125 lbs = 3+ g/d (Total Omega 3's)

vitamin D treatment protocol

30-75 lbs = up to 1000 iu/d 76-125 lbs = up to 2-3000 iu/d > 125 lbs = up to 4-5000iu/d Acute protocol: 50,000 iu once/twice per week for 8 weeks, recheck 25-OH (D) Recheck in 8 weeks

what percentage of the immune system is in the gut?

70% of immune system is in the gut

how many B vitamins?

8

Coeliac / Celiac disease (CD)

A chronic small intestinal immune-mediated enteropathy precipitated by exposure to dietary gluten in genetically predisposed individuals.

lactoferrin

A protein found in secretory fluids and neutrophils that inhibits microbial growth via iron chelation Sensitive marker of inflammation in the gut.

essential fat soluble vitamins

A, D, E, K

ABCDs of functional nutritional evaluation

Anthropometrics and vital signs Biomarkers & Labs Clinical Indicators (from The Nutrition Physical Exam) Diet and Lifestyle Assessment

essential water soluble vitamins

B vitamins vitamin C

thiamin

B1

niacin

B3

Pantothenic Acid

B5

biotin

B7

folate

B9

What Are The Components of GALT That Are Designed To Protect Us?

Dendritic cells Macrophages Commensal bacteria Goblet Cells Peyer's Patches Intra epithelial lymphocytes Immunoglobulins Interleukins Cytokines Neutrophils Toll-Like Receptors Regulatory T-cells (Th0) Pattern recognition receptors

DIGIN

Digestion / Absorption Intestinal Permeability Gut microbiota/dysbiosis Immune Modulation/Inflammation Nervous system

replace

Digestive factors Hydrochloric acid Pancreatic enzymes Bile salts Fiber to support transit and general GI function

FODMAPS

Fermentable Oligosaccharides Disaccharides Monosaccharides And Polyols

Celiac genes

HLA DQ2 & DQ8

Exposome

How internal metabolic factors and environment influences on our gene expression

Food allergy

Immunologic IgE-mediated type 1 hypersensitivity IgE- attaches to mast cells, gatekeeper for IgA t 1/2=2.3 days 1% total immunoglobulin memory (IL-4): up to years

food sensitivity

Immunologic reaction to food (IgA or IgG-mediated delayed hypersensitivity)

The Acute Inflammatory Response

Leukocyte stimulation / maturation Altered vascular rheology Increased production of: free radicals, inflammatory cytokines and chemokines, acute phase reactants (CRP)

Mucosal Immune System Critical 'Line of Defense'

NALT Nasopharynx-associated lymphoid tissue: Salivary glands Cervical lymph nodes Tonsils Adenoids Nervous System (Enteric Division) BALT Bronchus-Associated Lymphoid Tissue GALT Gut Associated Lymphoid Tissue Mesenteric Lymph nodes Isolated lymphoid follicles Peyer's patches Genital Tract-Associated lymphoid tissue Inguinal lymph nodes Para-aortic lymph nodes

Food intolerance

Non-immunologic reaction to food (e.g. lactose intolerance) •Lactose intolerance (lactase deficiency) •Tyramine, histamine (monoamines) •MSG, aspartame, sulfites •Salicylates (eicosanoid metabolism) •Lectins (indirect immune stimulation)

Putrefactive SCFAs

Predominant gut bacteria ferment dietary fiber and their monosaccharide components to acetate, propionate, and butyrate, and protein material to valerate, isovalerate and isobutyrate. •Serve as an important source of energy for colonocytes, liver cells, and skeletal muscle. Major SCFA's include acetate, propionate, and butyrate.

Gluten-related disorders

Recommended term to describe all conditions related to gluten. This may include disorders such as gluten ataxia, dermatitis herpetiformis, non-coeliac gluten sensitivity (NCGS) and CD

pancreatic elastase

Reflects overall enzyme production of the pancreas (amylase, lipase and protease) > 350 μg/g is normal

•Non-celiac gluten sensitivity (NCGS)

Relates to one or more of a variety of immunological, morphological or symptomatic manifestations that are precipitated by the ingestion of gluten in people in whom CD has been excluded.

Eosinophilic Protein X

Released in eosinophil degranulation •Sensitive marker of GI inflammation •May predict relapse in IBD May be elevated with: •Inflammatory Bowel Disease •Celiac Disease •Parasites •Allergic reaction •Less common •GERD •Chronic diarrhea •Chronic alcoholism •Protein-Losing Enteropathy

Fecal sIgA

Secretory IgA production is increased in the presence of potentially harmful antigens such as pathogenic bacteria, parasites, yeast, viruses, abnormal cell antigens, and allergenic proteins. Elevated fecal sIgA is useful in identifying if bacteria, yeast, or parasites are present. SIgA should renormalize with eradication of the pathogenic microorganisms.

Six Food Elimination Diet ( SFED)

Six Foods = milk, egg, wheat, soy, (legumes) peanut / tree nuts and seafood

omega 3 index

Total % of EPA + DHA in RBC fatty acids •Omega-3 Index of > or = 8% associated with the greatest cardioprotection

cobalamin

Vitamin B12

riboflavin

Vitamin B2

pyridoxine

Vitamin B6

cholecystokinin

a hormone that is secreted by cells in the duodenum and stimulates the release of bile into the intestine and the secretion of enzymes by the pancreas

Calprotectin

a protein released by neutrophils bacteriostatic -- stops bacteria from reproducing Elevated in: •Inflammatory Bowel Disease •Post-Infectious Irritable Bowel Syndrome •Gastrointestinal cancers •Certain gastrointestinal infections •NSAID enteropathy •Food allergy •Chronic Pancreatitis Use Calprotectin to Differentiate IBD vs. IBS: A person with positive Rome criteria and a normal Calprotectin (< 50 μg/g) has virtually NO CHANCE OF HAVING IBD! < 50 μg/g is normal

what might be causing increase in food reactions?

alterations of the Microbiome stemming from processed food

L-glutamine

amino acid The gastrointestinal tract is by far the greatest user of glutamine in the body, as enterocytes in the intestinal epithelium use glutamine as their principal metabolic fuel •2-4 g/d in divided dosages for wound healing and general intestinal support •10-40 g/d in divided dosages for critically ill and advanced disease

Beta-glucuronidase

an important lysosomal enzyme involved in the degradation of glucuronate-containing glycosaminoglycan The major producers of β-glucuronidase are colonic bacteria •β-glucuronidase activity is stimulated by tobacco, exposure to toxic substances and carcinogens, consumption of red meat, and antibiotic treatment. •Elevation of plasma β-Glucuronidase is considered as a marker of increased risk of developing hormone-dependent cancers, particularly cancers of the breast and prostate.

mediators

cytokines, prostanoids, nitric oxide, kinins, hormones, neurotransmitters, free radicals Hormones, Cytokines, etc. Ions ROS Metabolites Thoughts Beliefs Social Reinforcement Classical Conditioning

how does hypochlorhydria increase IgE reactions?

decreasing acidity increases IP so more intact proteins are let through the gut wall which leads to more unintended consequences ANYTHING that lowers gastric acid- aging, PPI, etc.

antecedents

experiences, past illness,occupational exposure, nutrition, lifestyle Congenital Demographic Dietary Habitual Environmental Occupational Learned Traumatic Disease-induced Drug-induced

GoToIt

gather organize tell order initiate track

triad of life

genes environment phenotype

Simplified elimination diet (Caveman Diet)

lamb, rice, pear, sweet potato

triggers

microbes, allergens, trauma, toxins, etc. Trauma Microbes Antigens Environmental Toxins Radiation Social Interactions Memories Diverse Sensory Stimuli

If someone has arthritis they may benefit by also excluding?

nightshades: potatoes, eggplant, peppers, tomatoes, cayenne, chili peppers

Eicosanoids

non classic- Antiinflammatory (resolution mediators) •Lipoxins: derived from AA •Resolvins: derived from EPA and DHA: (production enhanced by aspirin) •Protectins: derived from DHA •Epoxyeicosatrienoic acids = EETs: derived from EPA & AA via CYP450 epoxygenase Isoprostanes: marker of oxidative stress (nonenzymatic peroxidation of EFAs) Endocannabinoids(e.g. anandamide): derived from AA lead to neuropsychiatric effects classic- Prostanoids: generated by COX (•Prostaglandins •Prostacyclins •Thromboxanes) •Leukotrienes: generated by LOX

antibodies to the zonulin proteins suggests?

paracellular permeability (in between cells)

Reinoculate

prebiotics, probiotics, synbiotics

PFCMVP

protein, fats and oils, carbs, minerals, vitamins, phytonutrients

Eicosanoids

regulatory molecules that can be synthesized from omega-3 and omega-6 fatty acids •Signaling molecules produced by oxidation of 20-carbon long-chain PUFAs •Modulate all aspects of inflammatory reactions: rubor, tumor, calor, and dolor •Modulation of smooth muscle tone (vascular, uterine, bronchial, GI) •Modulation of vascular rheology •Influence nerve transmission and mood •Influence hormone secretion •Triglyceride lowering (via prostanoid binding to PPAR)

depression is caused by:

social isolation abx use autoimmune disease arthritis prediabetes vitamin D deficiency low thyroid omega 3 FA

Enteric Nervous System

the nervous system of the digestive tract a component of the autonomic nervous system ability to function independently of the central nervous system (CNS) gut microbiota modulates the function and the anatomy of the ENS through release of 5-HT and activation of the 5-HT receptor

epigenetics

the study of environmental influences on gene expression that occur without a DNA change How our environment shapes our structure and function

antibodies to the actomyosin networks suggests?

transccellular (through) intestinal permeability

rebalance

•'Scheduling' and relaxation •Mindful eating and better choices •Heart rate variability/ biofeedback •Yoga, meditation, prayer, breathing, or other centering practices •Psychotherapy

Triggers of Intestinal Permeability

•Alcohol •Additives •Gliadin protein •High fat diet •Simple sugars •HIIT •Zinc deficiency •Antibiotics •Concussions (TBI) •Night shift work •Oral contraceptives •Diarrhea •Constipation •Gastroenteritis •Hypochlorhydria •Autoimmune disease •Food allergies •NSAIDS •Stress/elevated cortisol •Obstructive sleep apnea •Cadmium exposure

Supporting Gastric Acidity

•Betaine HCL tablets (350-3500 mg) with protein-containing meal (spaced before & throughout the meal) •Umeboshi plums •Digestive enzymes with acid pH range •Swedish bitters •Gentian root •Vinegar •Decrease stress! •Increase vagal tone •Heart rate variability biofeedback

Signs and Symptoms Suggestive of Hypochlorhydria

•Bloating or belching immediately following a meal •A sense of fullness after eating •Itching around rectum •Weak, peeling, or cracked fingernails •Post-adolescent acne •Undigested food in stool •Dilated capillaries in face (acne rosacea) •Iron deficiency •Chronic intestinal infections •Multiple food allergies how to assess? •Clinical signs & symptoms •Betaine HCL challenge test

Non IgE: allergies heterogeneous group

•Celiac disease •Eosinophilic esophagitis •Eosinophilic gastroenteritis

food intolerances clinical factors

•Commensal Flora •Mucus layer •Intraepithelial Cells •Dendritic Cells •Micronutrients (e.g. Vit D & Vit A) •Macronutrients •Medications •CNS/Hormones/Stress

Natural Agents for Modulating Inflammation

•EFAs: •EPA/DHA:1000-4000 mg/d •GLA: 250-1200 mg/d (should be taken with at least 500 mg EPA to block AA production) •Niacinamide: 2000-5000 mg/d •Alpha lipoic acid: 300-1800 mg/d •N-acetylcysteine: 500-3000 mg/d •Probiotics: 10-100 billion CFUs qd

Locally Acting Inflammatory Mediators

•Eicosanoids(prostanoids, leukotrienes): leukocytes and most other cells •Platelet-activating factor: mast cells and basophils, neutrophils, platelets, endothelium •Angiotensin II: systemic circulation •Nitric oxide: endothelium, leukocytes, CNS •Endothelins(endothelium) -vasoconstrictors

Foundational Anti-inflammatory Protocol

•Elimination Diet •Probiotics •Vitamin D •Omega-3 Fatty Acids •L-Glutamine

Non-Celiac Gluten/Wheat Sensitivity (NCGC/NCWS):

•FODMAP reactions •Non-Celiac Gluten Sensitivity •Amylase-Trypsin Inhibitors (ATIs) •Wheat germ agglutinin (a lectin) •Other unidentified protein antigens/epitopes...?

prebiotics

•FOS •Guar •Lactulose •Inulin FOS/fructo-oligosaccharides, 1000-5000 mg, QD-TID •Inulin, 1000-5000 mg, QD-TID Fiber (high soluble) •Larch (arabinogalactans) 500-5000 mg, qD-TID •Modified citrus pectin, 3-5 g, BID-TID

ATMs Involved in Food Allergy (Risk factors for adult anaphylaxis are agents causing increased intestinal permeability)

•Genetics •Epidermal permeability •Medications •Environmental toxins •Nutrient deficiencies •Hypochlorhydria •Microbiota •Stress •Intestinal permeability

ATMs in IgG Food Sensitivity

•Genetics •Food and/or environmental allergy •Maldigestion •Dysbiosis •Nutritional insufficiencies •Intestinal permeability

Food-specific dietary restriction

•Gluten •Egg •Dairy •FODMAP •PALEO •Low Histamine

Inflammatory Autacoids: Locally Acting Inflammatory Mediators

•Histamine: mast cells, EC (enterochromaffin) cells, neurons, and most others •Bradykinin: systemic circulation (cleaved from HMW kininogen) •Serotonin: enterochromaffin cells (90%), platelets (sequestered), neurons •Tachykinins (e.g., substance P): gut, sensory neurons, CNS •Palmitoylethanolamide (PEA): local injury antagonist

Acute-Emergent MUSTs

•If IgE reaction dominant with positive history: Epi-Pen (at least two) •one for home •one for car •a third if active (one for backpack) •If reactive airways: rescue inhaler •If systemic reactions: antihistamine

Impairments in Digestion and Absorption

•Inadequate mastication •Hypochlorhydria •Pancreatic insufficiency •Bile insufficiency •Brush Border Injury

Signs and Symptoms Suggestive of Pancreatic enzyme insufficiency

•Indigestion/fullness 2-4 hours after meal •Bloating or flatulence 2-4 hours after meal •Undigested food in stool how to assess? Pancreatic elastase is measured in stool as indicator of exocrine pancreatic sufficiency

Maldigestion = Incomplete processing of food

•Insufficient HCL •Insufficient intestinal brush border enzymes •Decreased CCK stimulation of pancreas •Insufficient pancreatic enzymes •Insufficient bile acids

probiotics

•Lactobacillus sp. •reuteri •casei •rhamnosus •Acidophilus •Streptococcus sp. •Bifidobacterium sp. •infantis •lactis •longum •breve •Bifidum •S. boulardii (nonhuman) won't colonize the gut but will crowd out bad bacteria a probiotic yeast technically

probiotics

•Lactobacillus(various species): 10-100b cfu qD •Saccharomyces boulardii: 500 mg-3 g qD •Bifidobacterium(various species): 10-100b cfu qD •Probiotic mixtures: 10b -3.6 trillion cfu qD

Food Intolerances: Non-Immune Mediated Reactions

•Lactose intolerance (lactase deficiency) •Tyramine, histamine (monoamines) •MSG, aspartame, sulfites •Salicylates (eicosanoid metabolism) •Lectins (indirect immune stimulation)

AA/EPA Ratio

•Marker for eicosanoid balance -"cellular inflammation" •Ideal: < 3, you want 3x as much EPA as arachadonic acid

free radicals

•NADPH oxidase: O2-(superoxide) •Myeloperoxidase: HCIO (hypochlorous acid)

Repair

•Nutrients important for GI repair and healing: Glutamine, arginine, vitamin A, vitamin D, vitamin C, zinc, pantothenic acid, vitamin E, carotenoids •Mucosal lining support (e.g., phosphatidylcholine) •Mucosal secretion protectants such as phosphatidylcholine, plantain, polysaccharides •Support for GALT function (e.g., lactoferrin, lactoperoxidase, whey immunoglobulins) •Antioxidants known to function in the GI (e.g., catechins) •Nutritional and phytonutritional anti-inflammatories (e.g., curcumin, EPA, and DHA)

remove

•Oligoantigenic elimination diet •Botanical antimicrobials or bacteriostatic/bacteriocidal phytonutrients •Antibiotics/Antifungal medications

food allergies symptom control

•Pharmaceutical Bronchodilators: albuterol, ipratropium •Anti-histamines: Benadryl, Sudafed Zyrtec/Allegra/Claritin •Anti-leukotriene: Singulair •Anti-inflammatories: nasal or inhaled steroids •Mast Cell Stabilizers: cromolyn sulfate; ketotifen Botanical and Nutritional Symptom Control •Bronchodilation: Magnesium chelate, caffeine •Anti-histamine: Stinging nettles •Anti-leukotriene: Quercetin •Prostaglandin Balancing: Essential fatty acids •Anti-inflammatory: Essential fatty acids

Secretory IgA (sIgA)

•Predominant immunoglobulin released onto the surface of the GI mucosa. •Binds to and neutralizes microbes and other antigens before they can cross the mucosal barrier. more sensitive to having dysbiosis because less immune system in the gut

butyrate

•Primary energy source for enterocytes •Low if dysbiosis or low fiber

the 5Rs

•Remove •Replace •Reinoculate •Repair •Rebalance

Phytochemical Anti-inflammatories: Typical Doses

•Salicin(willow bark concentrate): 240-960 mg daily •Quercitin: 1500-3000 mg/d •Boswellia: 400-1200 mg/d •Curcumin: 500-1500 mg/d •Licorice root: 500-2000 mg/d •Grape seed extract: 150-300 mg/d Scute(Chinese skullcap): 1-2 g/d •Ginger root: 2-4 g/d •Milk thistle: 150-450 mg/d •Devil's claw root (Harpagophytum procumbens): 500-2000 mg/d •Ginkgo biloba: 80-320 mg/d

consequences of low HCL

•Small Intestinal Bacterial Overgrowth •Dysbiosis -altered gut bacteria •Chronic candida Infections •Mineral Deficiencies: Ca, Mg, Zn, Fe, Cr, Mo, Mn, Cu •B12 deficiency •Unexplained low ferritin or anemia

Molecular Inflammatory Triggers

•Trauma (mechanical, chemical, thermal, etc.) •Cellular debris (nucleic acids, mitochondria, etc.) •Pathogenic microbes •Advanced glycation end products •Toxins (organic chemicals, heavy metals, neoantigens) •Free radicals (oxidized lipids, glucose, proteins)

The Autoimmune Triad

•Trigger •Genetic Predisposition •Leaky Gut

Fecal Fat Testing

•Used to identify patients with steatorrhea/fat malabsorption, an important consideration for diagnosis and treatment •Common causes for an elevated fecal fat test include celiac disease, exocrine pancreas insufficiency, Crohn's disease, enteritis, or liver disease

GI immune enhancers

•Whey protein with concentrated immunoglobulins: 15-30 grams daily •Saccharomyces boulardii: 500 mg-3 grams daily •Glutamine 5-10 grams QD-TID •Larch (Arabinogalactans) 2-10 grams TID

secondary bile acids

•formed by bacterial metabolism of primary bile acids in the colon. •SBA are increased by dietary factors, primarily red meat and saturated fats. •Due to their hydrophobic nature, elevated levels of SBAs may cause damage to cell membranes, resulting in destruction of intestinal epithelium. •Elevated secondary bile acids associated with an increase in inflammatory cytokines in colonic mucosa •Increased levels of secondary bile acids, particularly deoxycholic acid and lithocolic acid, associated with increased incidence of colorectal cancer.